Healthcare Provider Details

I. General information

NPI: 1467711515
Provider Name (Legal Business Name): MARTIN FAMILY MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1357 W COLLIN RAYE DR
DE QUEEN AR
71832-2946
US

IV. Provider business mailing address

1357 W COLLIN RAYE DR
DE QUEEN AR
71832-2946
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-2000
  • Fax: 870-642-2005
Mailing address:
  • Phone: 870-642-2000
  • Fax: 870-642-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateAR

VIII. Authorized Official

Name: ANGELA K MARTIN
Title or Position: OWNER
Credential: APN
Phone: 870-642-2000